Healthcare Provider Details

I. General information

NPI: 1235413048
Provider Name (Legal Business Name): LAKE DRIVE CHIOPRACTIC CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2011
Last Update Date: 09/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8820 N HIGHWAY DR
CIRCLE PINES MN
55014-3907
US

IV. Provider business mailing address

8820 N HIGHWAY DR
CIRCLE PINES MN
55014-3907
US

V. Phone/Fax

Practice location:
  • Phone: 763-786-0670
  • Fax: 762-786-6423
Mailing address:
  • Phone: 763-786-0670
  • Fax: 762-786-6423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1497
License Number StateMN

VIII. Authorized Official

Name: DR. SCOTT J MURRAY
Title or Position: CHIROPRACTOR
Credential: MD
Phone: 763-786-0670